Claim Advocacy, Cost Effective Solutions and Providing Oversight Benefits

Utilizing an outside specialized service with a previous claimant to new claimant model creates a unique bond that can’t be matched by any other service in the nation. No one can understand what a current claimant is going through, unless they have been in their shoes. The trust factor that develops here is one that no adjuster, advocate, or counsel can emulate, unless they have had direct experience navigating their own workers’ compensation claim.  On the initial contact I personally speak with the claimant to solidify the trust factor before assigning it to my dedicated claims advocacy team members who have all been trained with our unique process.

On all subsequent communications, our team continues to reinforce with assuring the claimant if any issue at all transpires prior to our next scheduled communication, the claimant shall request a call from their claims advocate through their adjuster/ case/ or resolutions manager. This is where an outside past claimant to new claimant model truly shines and rises above all others which can’t be accomplished in house.

The advocacy model is that there is no one size fits all standard approach. An advocacy service must be custom tailored to your company’s specific needs, as each claim is unique. This makes it difficult for untrained in-house claims managers to implement. Claim managers and adjusters may try to empathize with the claimant, often in spite of their training, claims sustainable trust based connection is highly unlikely. The claimant’s life has been substantially uprooted, which may make them eager to seek out such guidance for litigation as any trust that develops here is short-lived when being implemented in house.

The breakdown in communication or other issues that transpire within the claims process becomes the catalyst for potential litigation or a carrier calling the claimant non-compliant or defiant, can be defused quickly and promptly as we obtain information from the claimant directly and reassure them how it’s better to work within the system to find an amicable resolution for the situation at hand. Working towards a positive mutual outcome for our clients, being the carrier/ third party administrator/ or employer continues in turn by helping the claimant when possible for alternative options while making forward progress for the return to work.

My team will immediately notify me shall the case need to be escalated directly to myself and discuss with the claimant personally. No model can offer this unique personalized outsourced claims advocacy service that can defuse the situation almost immediately with the past claimant to new claimant model with someone who understands exactly where the claimant is coming from and going. Working with alternative options for the claimant, just may be the difference between drastically increased administrative costs over the life of the claim vs. only the small possibility of minor expenses today.

One major advantage to working with our claim advocacy program, provides an additional oversight benefit for opioid abuse potential. Everyone involved in workers’ compensation claims from the carriers, third party administrators, employers, physicians, adjusters, and outside consultants need to be aware of this systemic problem within the industry. If you see something, say something. Being an industry with a broken model today, plagued with multiple issues, we must all take accountability to help the injured worker through this process. There is no such thing as a dumb question, except for the question never asked.

One advantage for example, after the first initial physician appointment, there may be a three week or more interval before the next follow up appointment. Additional diagnostic studies may have been requested during this initial examination only to be denied by the carrier for the cost incurred.  Meanwhile, the claimant may still be on opioids now for a longer period of time creating a growing issue.

Today, enough sufficient data exists showing a direct impact with 19% higher claim costs incurred over the life of the claim when opioids are involved. Shall the diagnostic study been approved early on, instead of masking the injury and waiting for the next appointment, the claimant could have been on the road to recovery with making forward progress for a prompt return to work and resolution of claim while the carrier, third party administrator or employer will experience reduced administrative costs.

As previously discussed, based on the Lockton report of 273,000 claims from 2013-2017 with a short option by risk and ( provides an eye opening article of information about rising costs of denied workers compensation claims which could have clearly been avoided. Claims initially denied only to be approved one year later carried a 55% higher cost per claim. Risk Managers need to start questioning if the correct approach taken on all their claims with this new found data.

Our Claims Advocacy pricing is based on services utilized. When a claim closes out early, our clients receive a pro-rated credit to utilize on any additional or new claim as we continue to redefine today’s process while helping benefit all parties involved.


Written By:

Paul Gold

Founder & CEO

PG Resolutions Group